<?php $fieldCounter = 0; ?>
<div class="page">
<table width="676" border="0" cellpadding="3" cellspacing="0">
	<tr>
	  <td colspan="3"><img src="/images/print/globelogo.png" alt="" width="120" height="50" border="0" /></td>
    <td align="right">Reference no.: <?php echo $application['ref_number'] ?></td>
	</tr>
	<tr>
	  <td colspan="4" style="background-color:#2f63af;"><h1>CORPORATE INDIVIDUAL</h1></td>
	</tr>
	<tr>
	  <td colspan="4" style="background-color:#011ca9;"><h2>PERSONAL INFORMATION</h2></td>
	  </tr>
	<tr>
	  <td width="20" valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td width="333" valign="top">ARE YOU AN EXISTING GLOBE TELECOM SUBSCRIBER?</td>
	  <td width="129" valign="top"><input type="checkbox" name="" value="" <?php echo ($application['existing_subscriber'] == 1) ? 'checked="checked"' : '' ?>  />&nbsp;YES</td>
	  <td width="170" valign="top"><input type="checkbox" name="" value="" <?php echo ($application['existing_subscriber'] == 0) ? 'checked="checked"' : '' ?> />&nbsp;NO</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td valign="top"><input type="checkbox" name="" value="" <?php echo (strlen($application['globe_mobile_access_code'].$application['globe_mobile_phone_number']) > 0) ? 'checked="checked"' : '' ?>  />GLOBE MOBILE PHONE&nbsp;&nbsp;&nbsp;MOBILE NUMBER</td>
	  <td valign="top">
      <?php for($i = 0; $i < 4; $i++): ?>
      <div class="txt">
        <?php echo (isset($application['globe_mobile_access_code'][$i])) ? $application['globe_mobile_access_code'][$i] : '' ?>
      </div>
      <?php endfor; ?>
	  </td>
	  <td valign="top">
      <?php for($i = 0; $i < 7; $i++): ?>
      <div class="txt">
        <?php echo (isset($application['globe_mobile_phone_number'][$i])) ? $application['globe_mobile_phone_number'][$i] : '' ?>
      </div>
      <?php endfor; ?>
	  </td>
	</tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td valign="top">&nbsp;</td>
	  <td valign="top">ACCESS CODE</td>
	  <td valign="top">PHONE NUMBER</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td valign="top"><input type="checkbox" name="" value="" <?php echo (strlen($application['globe_telephone_access_code'].$application['globe_telephone_phone_number']) > 0) ? 'checked="checked"' : '' ?> />
	    GLOBE LANDLINE&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;TELEPHONE NUMBER</td>
	  <td valign="top">
      <?php for($i = 0; $i < 4; $i++): ?>
      <div class="txt">
        <?php echo (isset($application['globe_telephone_access_code'][$i])) ? $application['globe_telephone_access_code'][$i] : '' ?>
      </div>
      <?php endfor; ?>
    </td>
	  <td valign="top">
      <?php for($i = 0; $i < 7; $i++): ?>
      <div class="txt">
        <?php echo (isset($application['globe_telephone_phone_number'][$i])) ? $application['globe_telephone_phone_number'][$i] : '' ?>
      </div>
      <?php endfor; ?>
    </td>
	</tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td valign="top">&nbsp;</td>
	  <td valign="top">ACCESS CODE</td>
	  <td valign="top">PHONE NUMBER</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td valign="top"><input type="checkbox" name="" value="" <?php echo (strlen($application['others_subscriber']) > 0) ? 'checked="checked"' : '' ?>  />
	    OTHERS, PLEASE SPECIFY</td>
	  <td valign="top" colspan="2">
      <?php echo (strlen($application['others_subscriber']) > 0) ? $application['others_subscriber'] : '&nbsp;' ?>
    </td>
	  </tr>
	<!--<tr>
	  <td valign="top"><?php //echo ++$fieldCounter; ?>.</td>
	  <td align="left" valign="top">
      <input type="checkbox" name="" value="" <?php //echo (isset($application['title']) && in_array(strtoupper($application['title']), array('MR','MR.'))) ? 'checked="checked"' : '' ?> />MR.&nbsp;&nbsp;&nbsp;
      <input type="checkbox" name="" value="" <?php //echo (isset($application['title']) && in_array(strtoupper($application['title']), array('MS','MS.'))) ? 'checked="checked"' : '' ?> />MS. &nbsp;&nbsp;&nbsp;
      <input type="checkbox" name="" value="" <?php //echo (isset($application['title']) && in_array(strtoupper($application['title']), array('MRS','MRS.'))) ? 'checked="checked"' : '' ?> />MRS.&nbsp;&nbsp;&nbsp;
      <?php //$othersTitle = (isset($application['title']) && !in_array(strtoupper($application['title']),array('MR','MR.','MS','MS.','MRS','MRS.'))) ? $application['title'] : '' ?>
      <input type="checkbox" name="" value="" <?php //echo ($othersTitle != '') ? 'checked="checked"' : '' ?> />OTHERS&nbsp;&nbsp;&nbsp;
    </td>
    <td colspan="2" valign="top" align="left"><?php //echo strtoupper($othersTitle) ?></td>
	</tr>-->
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.&nbsp;&nbsp;&nbsp;</td>
	  <td colspan="3" valign="top">SEX
      <input type="checkbox" name="input2" value="" <?php echo (strtoupper($application['sex']) == 'MALE') ? 'checked="checked"' : '' ?> />&nbsp;MALE&nbsp;&nbsp;&nbsp;
      <input type="checkbox" name="input2" value="" <?php echo (strtoupper($application['sex']) == 'FEMALE') ? 'checked="checked"' : '' ?> />&nbsp;FEMALE</td>
	  </tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="3" valign="top">
      <label>LAST NAME</label>
      <div class="longtxt"><?php echo (isset($application['last_name'])) ? $application['last_name'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="3" valign="top">
      <label>FIRST NAME</label>
      <div class="longtxt"><?php echo (isset($application['first_name'])) ? $application['first_name'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td height="19" valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="3" valign="top">
      <label>MIDDLE NAME</label>
      <div class="longtxt"><?php echo (isset($application['middle_name'])) ? $application['middle_name'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="3" valign="top">
      <label>BIRTHDAY<span>(mm/dd/yy)</span></label>
      <div class="longtxt"><?php echo (isset($application['birthday'])) ? date('m/d/y',strtotime($application['birthday'])) : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.&nbsp;&nbsp;</td>
	  <td colspan="3" valign="top">
      <label>MOTHER'S MAIDEN NAME(First, Middle, Last)</label>
      <div class="longtxt"><?php echo (isset($application['mothers_maiden_name'])) ? $application['mothers_maiden_name'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>. </td>
	  <td colspan="3" valign="top">HOME OWNERSHIP</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  	<td colspan="3" valign="top">
        <input type="checkbox" name="" value="" <?php echo (strtoupper($application['home_ownership']) == 'OWNED') ? 'checked="checked"' : '' ?>  />
            OWNED&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
            <input type="checkbox" name="" value="" <?php echo (strtoupper($application['home_ownership']) == 'LIVING WITH RELATIVES') ? 'checked="checked"' : '' ?> />
        LIVING WITH RELATIVES&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
	    <input type="checkbox" name="input5" value="" <?php echo (strtoupper($application['home_ownership']) == 'MORTGAGE') ? 'checked="checked"' : '' ?>  />
	    MORTGAGE (P <?php echo (isset($application['mortgage_per_month'])) ? number_format($application['mortgage_per_month']) : '' ?>/MONTH)</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="3" valign="top"><input type="checkbox" name="input22" value="" <?php echo (strtoupper($application['home_ownership']) == 'COMPANY-OWNED') ? 'checked="checked"' : '' ?> />
	    COMPANY OWNED &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  <input type="checkbox" name="input4" value="" <?php echo (strtoupper($application['home_ownership']) == 'RENTED') ? 'checked="checked"' : '' ?>  />
	    RENTED (P <?php echo (isset($application['rented_per_month'])) ? number_format($application['rented_per_month']) : '' ?>

	    /MONTH) </td>
	  </tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>. </td>
	  <td colspan="3" valign="top">
	    <label>YEARS OF STAY</label>
	    <div class="longtxt"><?php echo (isset($application['years_of_stay'])) ? $application['years_of_stay'] : '' ?></div>
	    </td>
	  </tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>. </td>
	  <td colspan="3" valign="top"><label>COMPLETE ADDRESS <span>(Room/Floor/BLDG. Name/No./Street)</span></label><br />
      <div class="longtxt"><?php echo (isset($application['home_address'])) ? $application['home_address'] : '' ?></div>
      </td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="3" valign="top"><label><span>(Brgy./Municipality/Town)</span></label>
      <div class="longtxt"><?php echo (isset($application['home_brgy_municipality_town'])) ? $application['home_brgy_municipality_town'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td height="19" valign="top">&nbsp;</td>
	  <td colspan="3" valign="top"><label>(City/Province)</label>
	    <div class="longtxt"><?php echo (isset($application['home_city_province'])) ? $application['home_city_province'] : '' ?></div>
	    <label><span>(Postal /Zip Code)</span></label><div class="shortxt-o"><?php echo (isset($application['home_postal_code_zip_code'])) ? $application['home_postal_code_zip_code'] : '' ?></div>
	    </td>
	  </tr>
	<tr valign="TOP">
	  <td height="19" valign="top"><?php echo ++$fieldCounter; ?>. </td>
	  <td valign="top"><label>HOME TELEPHONE NUMBER</label></td>
	  <td valign="top" colspan="2"><label>Area Code+Phone Number</label></td>
	  </tr>
	<tr>
	  <td height="19"><?php echo ++$fieldCounter; ?>. </td>
	  <td valign="top"><label>EMAIL ADDRESS</label>
      <div class="shortxt" style="width:200px"><?php echo (isset($application['email_address'])) ? $application['email_address'] : '' ?></div>
    </td>
	  <td valign="top" colspan="2">
      <div class="shortxt"><?php echo (isset($application['home_telephone_number'])) ? $application['home_telephone_number'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td height="19"><?php echo ++$fieldCounter; ?>. </td>
	  <td valign="top"><label>TIN</label>
      <div class="shortxt"><?php echo (isset($application['tin'])) ? $application['tin'] : '' ?></div>
    </td>
	  <td valign="top"><label>GSIS/SSS</label></td>
	  <td valign="top">
      <div class="shortxt"><?php echo (isset($application['gsis_sss'])) ? $application['gsis_sss'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td height="19"><?php echo ++$fieldCounter; ?>. </td>
	  <td valign="top"><label>CITIZENSHIP</label>
      <div class="shortxt"><?php echo (isset($application['citizenship'])) ? $application['citizenship'] : '' ?></div>
    </td>
	  <td valign="top"></td>
	  <td valign="top">&nbsp;</td>
	</tr>
	<tr>
	  <td height="19" valign="top"><?php echo ++$fieldCounter; ?>. </td>
	  <td valign="top"><label>If Foreigner (Country)</label>
      <div class="shortxt"><?php echo (isset($application['foreigner_country'])) ? $application['foreigner_country'] : '' ?></div>
    </td>
	  <td valign="top"><label>PASSPORT NUMBER</label></td>
	  <td valign="top">
      <div class="shortxt"><?php echo (isset($application['passport_number'])) ? $application['passport_number'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td height="19" valign="top">&nbsp;</td>
	  <td valign="top"><label>ACR No.</label>
      <div class="shortxt"><?php echo (isset($application['acr_number'])) ? $application['acr_number'] : '' ?></div>
    </td>
	  <td valign="top"><label>Passport Expiry Date</label></td>
	  <td valign="top">
      <div class="shortxt"><?php echo (isset($application['passport_expiry_date'])) ? $application['passport_expiry_date'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td><?php echo ++$fieldCounter; ?>. </td>
	  <td colspan="3">CIVIL STATUS&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
	    <input type="checkbox" name="input" value="" <?php echo (strtoupper($application['civil_status']) == 'SINGLE') ? 'checked="checked"' : '' ?>  />
	    Single&nbsp;&nbsp;&nbsp;
  <input type="checkbox" name="input" value="" <?php echo (strtoupper($application['civil_status']) == 'MARRIED') ? 'checked="checked"' : '' ?>  />
	    Married &nbsp;&nbsp;&nbsp;
  <input type="checkbox" name="input" value="" <?php echo (strtoupper($application['civil_status']) == 'WIDOW/WIDOWER') ? 'checked="checked"' : '' ?>  />
	    Widow/Widower&nbsp;&nbsp;&nbsp;
  <input type="checkbox" name="input" value="" <?php echo (strtoupper($application['civil_status']) == 'LEGALLY SEPARATED') ? 'checked="checked"' : '' ?>  />
	    Legally Separated</td>
	</tr>
	<tr>
	  <td><?php echo ++$fieldCounter; ?>. </td>
	  <td valign="top"><label>SPOUSE NAME(If applicable)</label>
      <div class="shortxt"><?php echo (isset($application['spouse_name'])) ? $application['spouse_name'] : '' ?></div>
    </td>
	  <td valign="top"><label>Date of Birth (Spouse)</label></td>
	  <td valign="top">
      <div class="shortxt"><?php echo (isset($application['spouse_birthday'])) ? date('m/d/y',strtotime($application['spouse_birthday'])) : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td><?php echo ++$fieldCounter; ?>. </td>
	  <td colspan="3"><label>Profession of Spouse/ Company Name</label>
      <div class="longtxt"><?php echo (isset($application['spouse_profession_company_name'])) ? $application['spouse_profession_company_name'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td height="19" valign="top"><?php echo ++$fieldCounter; ?>. </td>
	  <td colspan="3" valign="top"><label>POSITION</label>
      <div class="longtxt"><?php echo (isset($application['spouse_position'])) ? $application['spouse_position'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td height="19" valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="3" valign="top"><label>TELEPHONE NUMBER (Area code/ Phone number)</label>
      <div class="longtxt"><?php echo (isset($application['spouse_telephone_number'])) ? $application['spouse_telephone_number'] : '' ?></div>
    </td>
	</tr>
<!--	<tr>
	  <td height="19" valign="top">&nbsp;</td>
	  <td colspan="3" valign="top">
      <label>MSA No.</label>
      <div class="shortxt"><?php echo (isset($application['msa_number'])) ? $application['msa_number'] : '' ?></div>
    </td>
	</tr>-->
	</table>
</div>

<div class="page">
<table width="676" border="0" cellpadding="3" cellspacing="0">
	<tr>
	  <td colspan="4"><img src="/images/print/globelogo.png" alt="" width="120" height="50" border="0" /></td>
    <td align="right">Reference no.: <?php echo $application['ref_number'] ?></td>
	  </tr>
	<tr>
	  <td colspan="5" style="background-color:#2f63af;"><h1>CORPORATE INDIVIDUAL</h1></td>
	  </tr>
	<tr>
	  <td colspan="5" style="background-color:#011ca9;"><h2>EMPLOYMENT/FINANCIAL INFORMATION</h2></td>
	  </tr>
	<tr>
	  <td width="20" valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="4" valign="top"><label>EMPLOYER/BUSINESS NAME</label>
      <div class="longtxt"><?php echo (isset($application['employer_business_name'])) ? $application['employer_business_name'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="4" align="left" valign="top">INDUSTRY</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="2" valign="top">
      	<input type="checkbox" name="input2" value="" <?php echo (strtoupper($application['industry']) == 'BANKING AND FINANCE') ? 'checked="checked"' : '' ?>  />
      	BANKING AND FINANCE </td>
	  <td colspan="2" valign="top"><input type="checkbox" name="input3" value="" <?php echo (strtoupper($application['industry']) == 'IT/TELECOMMUNICATION') ? 'checked="checked"' : '' ?>  />
	    IT/TELECOMMUNICATION</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="2" valign="top"><input type="checkbox" name="input2" value="" <?php echo (strtoupper($application['industry']) == 'SERVICE') ? 'checked="checked"' : '' ?>  />
	    SERVICE</td>
    <?php $isIndustryOthers = (!in_array(strtoupper($application['industry']),array('BANKING AND FINANCE','IT/TELECOMMUNICATION','SERVICE','POWER/ENERGIES/UTILITIES','MANUFACTURING')) && $application['industry'] != ''); ?>
	  <td colspan="2" valign="top"><label><input type="checkbox" name="input6" value="" <?php echo ($isIndustryOthers) ? 'checked="checked"' : '' ?>  />
	    OTHERS, PLEASE SPECIFY</label>
      <div class="shortxt-o"><?php echo ($isIndustryOthers) ? $application['industry'] : '' ?></div>
    </td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="2" valign="top"><input type="checkbox" name="input" value="" <?php echo (strtoupper($application['industry']) == 'POWER/ENERGIES/UTILITIES') ? 'checked="checked"' : '' ?>  />
	    POWER/ENERGIES/UTILITIES</td>
	  <td colspan="2" valign="top"><input type="checkbox" name="input4" value="" <?php echo (strtoupper($application['industry']) == 'MANUFACTURING') ? 'checked="checked"' : '' ?>  /> MANUFACTURING</td>
	  </tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>. </td>
	  <td colspan="4" valign="top">
	    <label>COMPLETE BUSINESS ADDRESS <span>(Room/Floor/BLDG. Name/No./Street) </span></label>
	    <div class="longtxt"><?php echo (isset($application['business_address'])) ? $application['business_address'] : '' ?></div>
	    </td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="4" valign="top">
      <label><span>(Brgy./Municipality/Town)</span></label>
      <div class="longtxt"><?php echo (isset($application['business_brgy_municipality_town'])) ? $application['business_brgy_municipality_town'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td height="19" valign="top">&nbsp;</td>
	  <td colspan="4" valign="top"><label><span>(City/Province)</span></label>
      <div class="shortxt"><?php echo (isset($application['business_city_province'])) ? $application['business_city_province'] : '' ?></div>
      <label><span>(Postal Code/Zip Code)</span></label>
      <div class="shortxt"><?php echo (isset($application['business_postal_code_zip_code'])) ? $application['business_postal_code_zip_code'] : '' ?></div>
    </td>
	</tr>
	<tr valign="top">
	  <td height="19" valign="top"><?php echo ++$fieldCounter; ?>. </td>
	  <td valign="top" colspan="4">
      <label>OFFICE TELEPHONE NUMBER</label>
      <div class="shortxt"><?php echo (isset($application['office_telephone_number'])) ? $application['office_telephone_number'] : '' ?></div>
	</tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="2" valign="top">
      <label>YEARS IN COMPANY</label>
      <div class="shortxt"><?php echo (isset($application['years_in_company'])) ? $application['years_in_company'] : '' ?></div>
    </td>
	  <td colspan="2" valign="top">
      <label><?php echo ++$fieldCounter; ?>. CURRENT POSITION HELD</label>
      <div class="shortxt"><?php echo (isset($application['current_position_held'])) ? $application['current_position_held'] : '' ?></div>
    </td>
	  </tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="4" align="left" valign="top">PERSONAL MONTHLY INCOME</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="2" valign="top"><input type="checkbox" name="input5" value="" <?php echo (strtoupper($application['personal_monthly_income']) == 'BELOW P10,000') ? 'checked="checked"' : '' ?>  />
	    Below 10,000&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
	    <input type="checkbox" name="input7" value="" <?php echo (strtoupper($application['personal_monthly_income']) == 'P10,000 - P24,999') ? 'checked="checked"' : '' ?>  />
	    P 10,000 - P 24,999</td>
	  <td colspan="2" valign="top"><input type="checkbox" name="input5" value="" <?php echo (strtoupper($application['personal_monthly_income']) == 'P25,000 - P34,999') ? 'checked="checked"' : '' ?>  />
	    P 25,000 - P 34,999&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
	    <input type="checkbox" name="input8" value="" <?php echo (strtoupper($application['personal_monthly_income']) == 'ABOVE P35,000') ? 'checked="checked"' : '' ?> />
	    Above 35,000
    </td>
	</tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="4" valign="top">
      <label>AUTHORIZED PERSON IN YOUR ABSENCE</label>
      <div class="longtxt"><?php echo (isset($application['authorized_contact_person'])) ? $application['authorized_contact_person'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td width="143" valign="top">
      <label>RELATION</label>
      <div class="shortxt"><?php echo (isset($application['authorized_contact_relation'])) ? $application['authorized_contact_relation'] : '' ?></div>
    </td>
	  <td width="118" valign="top">
      <label>CONTACT NUMBER</label>
      <div class="shortxt"><?php echo (isset($application['authorized_contact_number'])) ? $application['authorized_contact_number'] : '' ?></div>
    </td>
	  <td valign="top" colspan="2">&nbsp;</td>
	  </tr>
	<tr>
	  <td colspan="5" style="background-color:#011ca9;"><h2>BILLS TO BE SENT TO MY:</h2></td>
	  </tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td valign="top"><input type="checkbox" name="input9" value="" <?php echo (strtoupper($application['bills_sent_to']) == 'HOME ADDRESS') ? 'checked="checked"' : '' ?>  />
	    Home Address</td>
	  <td valign="top">&nbsp;</td>
	  <td valign="top"><input type="checkbox" name="input10" value="" <?php echo (strtoupper($application['bills_sent_to']) == 'BUSINESS ADDRESS ') ? 'checked="checked"' : '' ?>  />
	    Office Address</td>
	  <td valign="top">&nbsp;</td>
	  </tr>
	<tr>
	  <td colspan="5" style="background-color:#011ca9;"><h2>SERVICE INFORMATION</h2></td>
	  </tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="4" valign="top">PLANS (Please refer to the table of GPlans / GFlex on opposite page)</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="4" valign="top"><label><input type="checkbox" name="input11" value="" <?php echo (strlen($application['plans_gplan']) > 0) ? 'checked="checked"' : '' ?>  />
	    GPlan &nbsp;&nbsp;&nbsp;&nbsp;</label>
      <div class="longtxt"><?php echo (isset($application['plans_gplan'])) ? $application['plans_gplan'] : '' ?></div>
    </td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  	<td colspan="4" valign="top"><label><input type="checkbox" name="input12" value="" <?php echo (strlen($application['plans_gflex']) > 0) ? 'checked="checked"' : '' ?>  />
GFlex&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </label>
        <div class="longtxt"><?php echo (isset($application['plans_gflex'])) ? $application['plans_gflex'] : '' ?></div>
      </td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="4" valign="top"><label><input type="checkbox" name="input13" value="" <?php echo (strlen($application['plans_others']) > 0) ? 'checked="checked"' : '' ?>  />
	    Others &nbsp;&nbsp;&nbsp;</label>
      <div class="longtxt"><?php echo (isset($application['plans_others'])) ? $application['plans_others'] : '' ?></div>
    </td>
	  </tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td valign="top">PROMO	    </td>
	  <td valign="top"><input type="checkbox" name="input20" value="" <?php echo (strtoupper($application['promo']) == 'NEW SUBSCRIPTION') ? 'checked="checked"' : '' ?>  />
New Subscription </td>
	  <td colspan="2" valign="top"><label><input type="checkbox" name="input21" value="" <?php echo (strtoupper($application['promo']) != 'NEW SUBSCRIPTION' && $application['promo'] != '') ? 'checked="checked"' : '' ?>  /> Others&nbsp;&nbsp;&nbsp;&nbsp;</label>
      <div class="shortxt" style="width:200px"><?php echo (strtoupper($application['promo']) != 'NEW SUBSCRIPTION' && $application['promo'] != '') ? $application['promo'] : '' ?></div>
    </td>
	  </tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>. </td>
	  <td colspan="4" valign="top">VALUE ADDED SERVICE / SPECIAL FEATURES</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="2" valign="top"><input type="checkbox" name="input14" value="" <?php echo (strtoupper($application['value_added_service_special_features']) == 'ACTIVATE AUTO DEBIT ARRANGEMENT') ? 'checked="checked"' : '' ?>  />Activate Auto Debit Arrangement<br />
<span style="font-size:11px; font-weight:normal;">Please Sign Auto Debit Arrangement Enrollment Form</span></td>
	  <td colspan="2" valign="top"><input type="checkbox" name="input16" value="" <?php echo (strtoupper($application['value_added_service_special_features']) == 'RECEIVE SMS NOTIFICATION ON NEW &AMP; EXISTING PROMOS') ? 'checked="checked"' : '' ?>  />Receive SMS Notification on new &amp; existing promos</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="2" valign="top"><input type="checkbox" name="input15" value="" <?php echo (strtoupper($application['value_added_service_special_features']) == 'DEACTIVATE INTERNAL ROAMING SERVICE') ? 'checked="checked"' : '' ?>  />
	    Deactivate Internal Roaming Service</td>
    <?php $isVASOthers = (!in_array(strtoupper($application['value_added_service_special_features']),array('ACTIVATE AUTO DEBIT ARRANGEMENT','RECEIVE SMS NOTIFICATION ON NEW &AMP; EXISTING PROMOS','DEACTIVATE INTERNAL ROAMING SERVICE')) && $application['value_added_service_special_features'] != ''); ?>
	  <td colspan="2" valign="top"><label><input type="checkbox" name="input17" value="" <?php echo ($isVASOthers) ? 'checked="checked"' : '' ?>  />
Others</label>
      <div class="shortxt-o"><?php echo ($isVASOthers) ? $application['value_added_service_special_features'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="4" valign="top">DEVICE INFORMATION</td>
	  </tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="4" valign="top"><label>Handset Brand/Model</label>
      <div class="longtxt"><?php echo (isset($application['handset_brand_model'])) ? $application['handset_brand_model'] : '' ?></div>
    </td>
	</tr>
	<tr>
	  <td valign="top">&nbsp;</td>
	  <td colspan="4" valign="top">Handset provided by
	    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <input type="checkbox" name="input18" value="" <?php echo (strtoupper($application['handset_provided_by']) == 'GLOBE TELECOM') ? 'checked="checked"' : '' ?> />
	    Globe&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input type="checkbox" name="input19" value="" <?php echo (strtoupper($application['handset_provided_by']) == 'SUBSCRIBER') ? 'checked="checked"' : '' ?> />
	    Subscriber</td>
	  </tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="2" valign="top"><label>HANDSET IMEI NO.</label>
      <div class="shortxt"><?php echo (isset($application['handset_imei_number'])) ? $application['handset_imei_number'] : '' ?></div>
    </td>
	  <td colspan="2" valign="top"><label>HBP</label>
      <div class="shortxt-o"><?php echo (isset($application['handset_hbp'])) ? $application['handset_hbp'] : '' ?></div>
      <label>LOCKUP PERIOD</label>
      <div class="shortxt-o"><?php echo (isset($application['handset_lockup_period'])) ? $application['handset_lockup_period'] : '' ?></div>
    </td>
	  </tr>
	<tr>
	  <td valign="top"><?php echo ++$fieldCounter; ?>.</td>
	  <td colspan="4" valign="top"><label>SIM CARD NUMBER</label>
      <div class="shortxt"><?php echo (isset($application['sim_card_number'])) ? $application['sim_card_number'] : '' ?></div>
    </td>
	</tr>
  <tr>
    <td><?php echo ++$fieldCounter; ?>.</td>
    <td colspan="4">
      <label><span>Authorized person to receive delivery</span></label>
      <div class="longtxt"><?php echo (isset($application['authorized_person_to_receive_delivery'])) ? $application['authorized_person_to_receive_delivery'] : '' ?></div>
    </td>
  </tr>
  <tr>
    <td valign="top">&nbsp;</td>
    <td colspan="4">
      <label><span>Complete delivery address</span></label>
      <div class="longtxt"><?php echo (isset($application['complete_delivery_address'])) ? $application['complete_delivery_address'] : '' ?></div>
    </td>
  </tr>
  </table>
</div>